A 44-year-old man comes to the office due to concern for hepatitis infection. The patient donated blood at an office blood drive event, and a few days later received a letter saying that hepatitis testing performed on his sample was positive. He has no chronic medical issues and feels healthy. He takes no medications. The patient does not smoke cigarettes and drinks alcohol at social events. He used injection drugs for several years in his 20s but not since then. He is in a monogamous relationship with his wife, who is also healthy. The patient works in a car dealership and is fairly active. Family history is significant only for hypertension in his father. Vital signs are normal. The sclerae are anicteric and mucous membranes are moist with no lesions. No lymphadenopathy is present. Lung fields are clear to auscultation and heart sounds are normal with no murmur. The abdomen is soft, nondistended, and nontender. There is no hepatomegaly or splenomegaly. He has no skin rash or extremity edema. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

A 44-year-old man comes to the office due to concern for hepatitis infection.  The patient donated blood at an office blood drive event, and a few days later received a letter saying that hepatitis testing performed on his sample was positive.  He has no chronic medical issues and feels healthy.  He takes no medications.  The patient does not smoke cigarettes and drinks alcohol at social events.  He used injection drugs for several years in his 20s but not since then.  He is in a monogamous relationship with his wife, who is also healthy.  The patient works in a car dealership and is fairly active.  Family history is significant only for hypertension in his father.  Vital signs are normal.  The sclerae are anicteric and mucous membranes are moist with no lesions.  No lymphadenopathy is present.  Lung fields are clear to auscultation and heart sounds are normal with no murmur.  The abdomen is soft, nondistended, and nontender.  There is no hepatomegaly or splenomegaly.  He has no skin rash or extremity edema.  Laboratory results are as follows:  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Hepatitis C virus (HCV) is transmitted most efficiently through percutaneous exposure to blood. As such, most cases in the Western world arise in those with a history of intravenous drug use. Initial infections are usually asymptomatic, but most lead to chronic hepatic infection, putting patients at risk for cirrhosis and hepatocellular carcinoma. Screening for HCV is primarily done using HCV antibody testing; a positive test indicates one of the following: Active, ongoing infection (chronic or acute) Past infection that has resolved False-positive result HCV antibody testing is used for screening, as it identifies those exposed to the virus. To determine which patients have ongoing, active disease, further testing is required to document HCV RNA in the blood. This is accomplished with HCV nucleic acid testing (NAT). Patients with positive HCV NAT are candidates for treatment with antiviral therapy. Chronic HCV infection is usually asymptomatic, and approximately one third of patients have normal liver function testing. As such, symptoms and basic laboratory assessment cannot be used to identify those with chronic versus cleared infection (Choice C). (Choice A) The diagnosis of chronic HCV infection is a 2-step process that requires a positive serologic test result for the HCV antibody and a confirmatory molecular test for the presence of circulating HCV RNA. This patient requires additional testing to confirm HCV RNA. (Choices D and E) Patients with positive HCV NAT should undergo further evaluation to identify the HCV genotype and the extent of liver fibrosis (eg, liver biopsy); aminotransferases do not provide a clear picture of disease progression. Confirmation with HCV NAT is required. Educational objective: A positive serologic test for hepatitis C virus (HCV) requires further investigation to evaluate for chronic infection. In asymptomatic patients, 3 potential explanations should be considered: persistent infection, cleared infection, or false-positive antibody test. Diagnosis of chronic HCV requires both a positive serologic test and a confirmatory nucleic acid test to confirm HCV RNA in the blood. References: Diagnosis and management of hepatitis C. (http://www.ncbi.nlm.nih.gov/pubmed/26131943)

A 44-Year-Old Man Comes to the Office Due to Concern